Provider Demographics
NPI:1205688421
Name:KELLY, EMILEE (AGNP)
Entity type:Individual
Prefix:
First Name:EMILEE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9980 S 300 W STE 300
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3654
Mailing Address - Country:US
Mailing Address - Phone:801-253-6886
Mailing Address - Fax:385-900-5928
Practice Address - Street 1:2019 E RIVERSIDE DR STE A101
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8147
Practice Address - Country:US
Practice Address - Phone:801-253-6886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6925143-3102163WW0000X
UT6925143-4405363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner